What is Fibromyalgia? Who gets it? What causes it? How is it diagnosed? Is there a cure? What are the best treatments?
These questions and more are answered in this blog.
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What Is Fibromyalgia?
Fibromyalgia (FM), or “fibromyalgia syndrome (FMS)”, is classified as a “chronic disorder characterized by widespread and persistent non-inflammatory musculoskeletal pain.” Common symptoms associated with FM include:
- Widespread musculoskeletal pain
- Fatigue
- Insomnia
- Morning stiffness
- Depression
- Anxiety
- Mental slowness
- Memory and attention problems
How Common Is Fibromyalgia?
As of 2013, 2.7% (4.2% of women and 1.4% of men) of the global population had the diagnostic label of fibromyalgia. The prevalence of FM appears to increase steadily with age in women and peak during middle age in men.
Traditionally, FM was considered a predominantly female disorder and it was relatively uncommon for men to receive the diagnosis. Recently, however, Galvez – Sanchez et al in 2020 noted that bias within research and clinical practice leads (and has led) healthcare providers to underestimate fibromyalgia prevalence in men and overestimate it in women.
With newer diagnostic criteria and a less biased selection of patients, the female proportion drops to 60% or less.
What Causes Fibromyalgia?
As reported by the Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome, the cause of FM is still unknown. However, a host of biological, psychological, and social factors may contribute to the onset and severity of fibromyalgia.
As noted by Fitzcharles et al in 2012, “the expression of FM may be explained by a biopsychosocial model in which predisposition, triggering and other factors, such as depression, maladaptive coping or fear-avoidance behavior, contribute to chronicity.”
How Is Fibromyalgia Diagnosed?
Previously, Wolfe et al in 1990 and the American College of Rheumatology created the diagnostic criteria for FM. This criteria included both chronic widespread pain (ie. pain on both sides of the body, above and below the waist, and at least one portion of the spine, for at least 3 months) and “tenderness” in at least 11 of 18 defined specific locations; classified as tender points. The tender point exam continues to be widely referred to and discussed; however, this exam is no longer recommended within the updated FM diagnostic criteria.
“A second aspect that is highlighted is the fallacy associated with the tender point examination, a mainly subjective technique that is not supported by sound scientific basis and has been fraught with controversy. Therefore, contrary to previous beliefs, examination of tender points should not be used to either confirm or validate a diagnosis of FM.” Fitzcharles et al in 2012
Currently, the 2016 Revisions to the 2010/2011 American College of Rheumatology (ACR) Diagnostic Criteria are utilized as the primary means of diagnosis. There are two scales involved, the Widespread Pain Index (WPI) and the Symptoms Severity Scale (SSS):
- WPI – a list of 19 painful areas (score range: 0-19)
- SSS – includes 2 parts: Part SS2a, evaluating the severity of fatigue, waking unrefreshed, and cognitive symptoms, and Part SS2b, a checklist of 41 symptoms (including IBS, fatigue/tiredness, muscle weakness, Raynaud’s, ringing in the ears, etc.)
Per the updated 2016 revision of the 2010/2011 ACR criteria, there are three components that need to be met for an individual to be diagnosed with fibromyalgia:
- Generalized pain, defined in at least 4 of 5 bodily regions (i.e., left and right upper, left and right lower, and axial)
- Symptoms have been present at a similar level for at least 3 months
- WPI greater than or equal to 7 and SSS greater than or equal to 5 OR WPI of 4-6 and SSS score greater than or equal to 9
In the original 2010 American College of Rheumatology Criteria, “the patient does not have a disorder that would otherwise explain the pain”, was the third and final condition that had to be met. However, this was revised by Wolf et al in 2016, noting that, “a diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis does not exclude the presence of other clinically important illnesses.”
Lastly, the fibromyalgia severity (FS) scale is calculated by adding the WPI and SSS scores, providing a total score between 0-31. A score of 0 represents no symptoms and a score of 31 represents the most severe symptoms. Wolf et al in 2016 recommend that the FS score always be reported and “a subsequent score <12 might be used as a measure of improvement or of current status.”
The updated fibromyalgia diagnostic criteria from Wolf et al in 2016 can be seen here.
Are We Pathologizing Normal?
As a brief aside, but something that should be considered, researchers have raised concerns for the “diagnostic expansion” of fibromyalgia. In this case, diagnostic expansion simply means lowering the bar for what classifies as fibromyalgia.
Higher chances of overdiagnosis, potential overmedicalization, and pathologizing of otherwise normal human experiences become a concern when too many people are unnecessarily labeled (up to 75%) with the clinical diagnosis of fibromyalgia as reported by Walitt et al in 2016.
Who Should Be Diagnosing Fibromyalgia?
The 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome report that FM should be diagnosed in the primary care setting. These guidelines suggest that seeking a specialist for the care of FM offers no clear advantage and does not improve long-term outcomes.
“Because the primary care physician has the best knowledge of the patient from the biopsychosocial perspective and is likely to have been managing the patient over time, the primary care setting must be the focal point for management.” Fitzcharles et al in 2012
The guideline also reports that excessive clinical investigation should be minimized (i.e. limiting unnecessary tests and procedures) and only simple laboratory tests should be performed to rule out other identifiable conditions including: hypothyroidism, rheumatic conditions, neurological disease, or drug-induced conditions.
Is There A Cure?
Currently, there is no known cure for fibromyalgia. Knowing this, the focus must shift towards developing long-term strategies to effectively cope with and self-manage this condition.
“The health care community should discourage passive health-related practices and excessive dependence on health care professionals. Although clinic visits may be more frequent at a treatment initiation, reduction of unnecessary health care contact when the patient is on a stable trajectory is mandatory.” Fitzcharles et al in 2012
What Are The Treatment Options?
The European League Against Rheumatism (EULAR) recommendations for the management of FM includes:
Non-Pharmacological Management:
- Aerobic and Strengthening Exercise (Strength of Recommendation: Strong)
- Cognitive Behavioral Therapies (Strength of Recommendation: Weak)
- Multicomponent Therapies (Strength of Recommendation: Weak)
- Defined Physical Therapies: acupuncture or hydrotherapy (Strength of Recommendation: Weak)
- Meditative Movement Therapies (Strength of Recommendation: Weak)
Pharmacological Management:
- Amitriptyline (Strength of Recommendation: Weak)
- Duloxetine or Milnacipran (Strength of Recommendation: Weak)
- Tramadol (Strength of Recommendation: Weak)
- Pregabalin (Strength of Recommendation: Weak)
- Cyclobenzaprine (Strength of Recommendation: Weak)
One primary overarching principle created from the EULAR group is:
“Management of fibromyalgia should aim at improving health-related quality of life balancing benefit and risk of treatment that often requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, and associated features (such as depression), fatigue, sleep disturbance and patient preferences and comorbidities; by shared decision making with the patient. Initial management should focus on non-pharmacological therapies.”
Listed below are the management recommendations turned into a flow chart from Macfarlane et al in 2016.
As outlined earlier, aerobic and strengthening exercise was the only management option receiving a “strong” level recommendation. The next section will elaborate on the safety, types, and prescription of exercise for those diagnosed with FM.
Exercise Recommendations
Multiple clinical practice guidelines and consensus groups, including Miedany et al in 2022, Macfarlane et al in 2016, Fitzcharles et al in 2012, Brosseau et al in 2008, and Houser et al in 2008 recommend exercise as the cornerstone of treatment for those diagnosed with fibromyalgia. Exercise has demonstrated improvements in pain, physical function, and health related quality of life in this population across a variety of modes and intensities:
Aquatic Exercise: A Cochrane systematic review by Bidonde et al in 2014 states that, “Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia.”
Land-Based Aerobic Training: A Cochrane systematic review by Bidonde et al in 2017 concludes that, “When compared with control, moderate-quality evidence indicates that aerobic exercise probably improves HRQL [health related quality of life] and all-cause withdrawal, and low-quality evidence suggests that aerobic exercise may slightly decrease pain intensity, may slightly improve physical function, and may lead to little difference in fatigue and stiffness.”
Resistance Training: A Cochrane systematic review by Busch et al in 2013 highlights that, “moderate and moderate- to high-intensity resistance training improves multidimensional function, pain, tenderness, and muscle strength in women with fibromyalgia.” Additionally, a more recent systematic review by Andrade et al in 2018 reports that, “ST [strength training] is a safe and effective method of improving the major symptoms of FM and can be used to treat patients with this condition.”
Mixed Exercise: A Cochrane systematic review by Bidonde et al in 2019 reports that, “Compared to control, moderate-quality evidence indicates that mixed exercise probably improves HRQL [health related quality of life], physical function, and fatigue, but this improvement may be small and clinically unimportant for some participants; physical function shows improvement in all participants.” Mixed exercise was defined as two more types of exercise including resistance, aerobic, and flexibility.
High-Intensity Interval Training: A 5-year pilot study by Bodere et al in 2020 notes that, “FM patients who were active (with both MICT [moderate intensity continuing training] and HIIT) during the 5 years have a very significant improvement in overall symptoms compared to the other two groups (LICT [low intensity continuous training] and passive).”
Which Form Of Exercise Is Best?
There is no specific type of exercise or mode of training that has to be performed for individuals with FM. Individuals should select activities that they enjoy, have frequent/easy access to, are progressive in nature, and will allow them to work towards meeting or exceeding the current national physical activity guidelines.
“In the absence of a single exercise program outperforming others, patients should be encouraged to choose an activity either land based or water, that is enjoyable, easy to follow, convenient and within budget in order to improve adherence.” Fitzcharles et al in 2012
How Much Is Too Much?
There is no upper threshold reported in the literature regarding how much activity and exercise is considered too much for those diagnosed with fibromyalgia. Our general recommendation, as noted in previous E3 Rehab articles, YouTube videos, and podcasts, is to find an entry point for daily/weekly activity and exercise that matches your current capacity and symptom tolerance.
As an example, someone just starting out may be only able to tolerate 5-10 minutes of walking outside, a few times per day, and 1x per week of low intensity resistance based exercise. That same individual, months or years down the road, might be able to tolerate higher intensity resistance training and 5+ mile runs, multiple times per week.
Ultimately, the goal is to increase an individual’s capacity over weeks, months, and years, with the understanding that there will be natural fluctuations in symptoms throughout this process.
Summary
- There is no known cause for the development of fibromyalgia. The diagnosis itself and how it is diagnosed is still called into question.
- Diagnostic criteria for fibromyalgia has evolved over time and the current version is based on the 2016 revised 2010/2011 ACR Criteria.
- Due to the diagnostic expansion of fibromyalgia, there is a concern surrounding the overdiagnosis and over medicalization of this condition.
- There is no known cure for fibromyalgia, and the focus must shift towards developing long-term strategies to effectively cope with and self-manage this condition.
- Progressive aerobic exercise and resistance training to maintain or improve overall physical function and health status should form the cornerstone of treatment.
- Currently, there is no specific exercise program that’s recommended for this population. Individuals should select activities that they enjoy, have frequent/easy access to, are progressive in nature, and will allow them to work towards meeting or exceeding the current national physical activity guidelines.
If you are still unsure where to start or how to progress and would like 1-on-1 guidance, you can reach out to our E3 Rehab Coaching team for remote consultations and programming.
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